Austin Frakt has been doing an excellent job of reviewing the literature on this subject. This is from an overview of his recent posts:

The proportion of hospitalizations leading to rapid readmissions is shocking…But what causes readmissions?…Is this the fault of hospitals? Evidence about the extent to which hospital readmissions are related to quality of care during the index admission is mixed. Readmissions may be related to some notions of hospital quality or safety but not others. They are also related to many other factors that are not amenable to modification by hospitals. Joynt and Jha offer the most compelling and complete case that variation in socioeconomic status and hospital resources play large roles in variation in readmission rates. Hospitals that lose resources due to high readmission rates may be the very ones that can least afford it. Quality may suffer for the most vulnerable populations, which is the opposite of the policy’s goal…

Comments (10)

High readmission may not reflect poor quality, as Frakt is quick to point: high readmission rates can be the result of low mortality rates or good access to hospital care. Indeed, some studies show that improved external care coordination and access to follow-up care actually increases readmissions. This should hardly be indicative of a failure of our health systems.

We wouldn’t be worried about readmissions or whether they are avoidable if Medicare would allow hospitals like Geisinger Health System (Pennsylvania) to propose new pays of getting reimbursed. A few years ago Geisinger offered insurers a 90-day warranty where it would pay for all complications are follow-up care in the event something went wrong. All it wanted in return was a higher reimbursement sufficient to save Medicare money and cut some of the losses Geisinger would sustain offering a warranty for free. Medicare did not have the flexibility to take Geisinger up on its offer.

I read into some of Geisinger’s policies and procedures a few years ago. If I remember correctly, all of their physicians are employed physicians, and they receive benefits and bonuses based on quality of care metrics – such as readmission rates, hospital acquired infections and pneumonia, and mortality rates (for oncology patients).
After these policies were enacted, Geisinger has enjoyed some of the most efficient ratings of any hospital in the world.

Is it perhaps that these cases studies – acute myocardial infarctions (AMI), pneumonia, and total hip arthroplasty (THA) – are highly correlated with lower quality health?

When I worked at Stanford Hospital, most THA patients were elderly, obese, or both. Most pneumonia patients were already infirm, and at least half of the AMI patients I could not call anywhere near pictures of perfect health.

Perhaps the reason for the readmission rates is that these patients truly need the care.

Frakt is an excellent researcher and writer, but I for one am not concerned about readmissions.

Here are two reasons:

– There were less readmissions before 1970, because a lot of patients never left the hospital in the first place. Dwight Eisenhower stayed in hospital for over 20 days after his heart attack in 1955.

I had a similar heart attack in 2008 and stayed five days.

There is an accounting problem with readmissions, but that is all there is.

– Due in large part to Medicare and Medicaid, there are more 85+ year olds who survive on death’s door step than there ever used to be. Dialysis, transplants, and chemotherapy are just the most dramatic examples. These people would have been dead 30 years ago.

Health issues like diabetes or heart disease would necessarily have readmissions. It is sad that private-sector innovations like the offer that Geisinger Health System put forward cannot be implemented due to the rigidity of the Medicare.